Health care is too nuanced for lengthy scripts

Recently in one of the Johns Hopkins Hospital’s intensive care units, a patient was dying from cancer and sepsis, and there was nothing that I, nurse Mandy Schwartz or anyone else could do to stop it. Yet as the patient’s family — two daughters and a husband — suffered at her bedside, Mandy saw their need for comfort, and she responded. Although she was busy with nursing tasks, she delved into the inner life of the patient and family. She helped the mother look as good as possible — hair combed, face washed, a clean gown and sheets. She made sure the patient was pain-free and not anxious. She hugged one daughter who was “a hugger” and avoided embracing the other daughter who wasn’t. She sat with the family, listened and supported them in their anguish.

Schwartz gave comfort to the family because she cares and has true empathy.  There’s no way that we could train her to care more. Yet too often, efforts by hospitals to improve the patient and family experience approach it purely as a technical challenge. For instance, we provide scripts to health care professionals to help them navigate various situations, from what to say when walking into a patient’s room to service recovery when things haven’t gone as they wished.  We try to identify and broadly implement the practices that will best enhance patient experiences, such as rounding hourly in patient rooms to address pain management, bathroom visits and other needs.

These are well-intentioned and needed efforts to improve the patient experience. But they could very well backfire if we don’t simultaneously embrace the human element and tap into clinicians’ desire to be empathic healers and comforters. I fear that we send the wrong message, for instance, when we simply hand detailed scripts to staff in low-performing units or hospitals. Subtly, we’re labeling them as someone who does not care adequately for patients, and that they need to be taught how to do better. “Here,” we say, “mouth these words and the patient and loved ones will believe that you care.” Likewise, hourly rounding and other interventions will not be effective if we simply treat them as a box to be checked off.

Words are important, of course. And caregivers can certainly learn how to insert key words and phrases into their conversations with patients to show they care and open the door to more meaningful dialogue. However, health care is too complex and nuanced for a lengthy script to be useful.

Clinicians witness the extreme highs and lows of other people’s lives, yet like any job this becomes our everyday reality, with mundane documentation, meetings and bureaucracy. It’s easy to forget that “just like me” someone may be in the hospital for the first time, that their family members must take off work for an extended period of time to be with them, or that the outcome of their stay is a turning point in their family’s future.

When we lose sight of the connection with our common humanity, with our patients’ suffering, we can fail to connect with our patients’ needs for empathy as well as healing.  We can get so caught up in the tasks that we need to do that we don’t stop to care. While we think we are still delivering good care, patients perceive our frenzied state and decide it’s wiser not to raise valid concerns.

What can help us to reverse this?

There’s more than a single thing, but one powerful approach involves coaching caregivers on their interactions with patients and loved ones. On a surgical unit in the Johns Hopkins Hospital, scores on HCAHPS — the national post-discharge survey sent to patients after discharge — were far below national averages. In their written responses, some patients said that they felt unwelcome to raise concerns, or that staff made them feel like a burden.

The low scores understandably got the hospital’s attention, leading to a partnership between the unit and service excellence department. As part of their response, Debbie Miller, project administrator in service excellence, began to listen in on their conversations with patients from outside of the patient rooms. When these caregivers emerged, Miller would coach them, providing feedback and suggesting what they might have done to improve the patient experience.

At times, Miller would guide them on how to rephrase what they had said so that patients felt better about their experience and more welcome to share concerns. She showed them how they could incorporate key phrases into their discussions (such as “What is your goal today?” or “I’m listening to what you’re telling me …”) to reinforce their concern for the patient as a person. She also put together a list of 12 key (and simple) behaviors  to be incorporated into every encounter, such as introducing themselves by name, asking the patients how they want to be addressed and use that name, making frequent eye contact, and allowing patients to tell stories without interruption.

At its heart, she says, her approach was about getting caregivers to shift their focus when interacting with patients, from completing tasks to having meaningful conversations that forge a personal connection and build trust. And it doesn’t have to take long, she says. The little things, such as taking time to ask if a patient needs a bed bath or teeth brushed, can have a big impact.

The unit’s scores on HCAHPS grew quickly, and impressively. Within several months, scores typically ranked well above the 90th percentile. In April 2014, they were in the 97th. “My admission was the best experience ever,” write one patient in the survey. “My visitors and family enjoyed the helpfulness of the employees,” wrote another.

Clinicians sometimes need a reminder of our common humanity with patients, allowing us to realize that “just like me” they might be worried, scared or suffering. If we see the connections to patients and find a way to tap into our inner strength as caregivers, empathy will flourish and we can figure out the best way to respond, as Schwartz did. We will know that we should introduce ourselves by name, smile, ask the patient what name they like to be called, look them in the eye, and ask them if there’s anything we can do for them. Hourly rounding will not seem a burden, but rather a blessing. Clinicians will make rounds in patient’s rooms and conduct shift reports at the bedside, to make sure that patients and family members are involved in the care plan, know what’s going on and are able to ask questions. We will recognize the nuances of a patient’s situation that no script could prepare us for.

Peter Pronovost is an anesthesiologist and director, Armstrong Institute for Patient Safety and Quality.  He blogs at Points from Pronovost.

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  • JR

    Scripts are very useful, but they have to be used very carefully. They are a beginning point, a training point, NOT a goal. They are best used when training a new employee.

    I think it’s interesting that as a counterpoint you argue to use… what I would describe as using scripts! “Key phrases” – those are scripts!

    Don’t say “I don’t know”. Say “that’s a good question”. The first sounds like you aren’t going to help them, the second sounds like you care. I learned that from a cheesy training tape but I use it all the time because it works.

    People really CAN be taught to interact with others better. It’s not just a “you’re a people person or you’re not”. I’ve seen people learn and grow and change before, so I know it’s possible. However – they have to want to learn to do it. If they don’t believe they can change they will fail.

    • Patient Kit

      “I don’t know but I’ll find out for you.” is good too. There’s something very genuine about admitting when you don’t know something. As a patient, I do respond well when my doc says “That’s a good question.” and even better when he responds with a good answer, immediately or once he finds out for me.

      I understand the purpose but, in general, I’m not a big fan of scripts unless they are used by people who can truly pull off sounding unscripted and sincere. People who sound scripted are a real turn off, in healthcare and elsewhere, because they sound insincere and generic. I prefer people to get some interpersonal communications tips but remain free to be themselves. I realize there are cultural differences but eye contact is important to me. I don’t trust anyone who won’t make eye contact with me.

      • JR

        Scripts are a great starting point to teach employee’s who are in training. Usually they are accompanied with key points that need to be hit (such as “introduce yourself”).

        What you don’t want is a script that is written and employees are told “you must follow this word for word, letter by letter”. Then it’s being used as a form of control and not a learning tool.

        However, It’s not the script that is the problem, but rather the implementation of it. Instead of “all scripts are bad” – rather than “use them right”. “All surveys are bad” instead of “how to use them right”. We don’t get posts that say “all screening is bad” – instead we get discussions of the nuances of screening and the pros and cons. I feel that way about scripts – there is both good and bad ways to use them.

  • Anne-Marie

    Sometimes it’s hard for people to find the right words, especially when they’re under pressure. Even experienced health care professionals could use a few key phrases to fall back on in difficult or challenging situations.

    Health care folks can become so used to how they talk and what they do that they forget about the patient’s perspective. Let’s start with those unfriendly-sounding notices plastered all over the reception desk — I mean, I know you need to have some rules about cell phones and copays and whatnot, but surely they can be presented in a way that doesn’t bash patients over the head.

    IME the vast majority of people in health care are good at what they do and possessed wonderful empathy, but I have encountered one or two who were sadly lacking in interpersonal skills and it showed. Training and scripting might have helped smooth over the worst of their rough edges (although then again, maybe not).

  • SteveCaley

    A script is a special, poignant way of letting someone know you really don’t care enough to speak with them genuinely. It is a powerful construct of a fictive sincerity produced in a cubical far, far away. It is Hallmark Medicine. Perhaps they can just sit in a room, and the hospital can contract for a Famous Actor to read a prerecorded speech to the suffering loved ones. We sanitize medicine, a thing that cannot be sanitized because it is human, and thus a messy thing.

    I have attended in hospice. Some patients and families take the transition in peaceful, spiritual ways. Some families take the transition with lots of screaming, hitting and drinking. It is none of my damn business whether they are tidy and likeable, or irritating and horrible. People gotta deal with things exactly the way they do. Who am I to tell them how they should behave at the passage of life? The only script to be read is, “I am here for you. How are you?” The rest of the sonorant passages are just prefabricated ways to push away untidiness with a stick. You are not composed – you are disheveled, and full of emotion. Shame on you! says the underlying message. I do not know how to deal with you – that is why we have technical writers to prefabricate sympathy. Now sign here that I read this to you.

    And we hold our heads up and claim we are civilized?

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